51075.5 (4) i a sJ
c No. Street Lot No.
o —
a APP,LIC'A�IONT4 RvPLWMISIN RMIT
U ) CCFY:OF-CUP R-YIN
OCT 18 1968 S t!�j No
�F. Date 196 6;7 Permit No�yy 7S',S
3 CITY Or CUPERTINO Fee Ste_
Application is hereby made to the City of Cupertino for a permit to install plumbing pipes
and/or fixtures listed on the reverse side hereof,and agrees to install said prices and/or fixtures
`o in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
'c laws applicable thereto.
A Use of Premises r.J /lOC�4...--.•�/ /`l�_�
o v
Owner f'�(7 x/ �C 7- 0107 Address
c BY dyGL f-/X-- 4- Address GJ�y�70'�tti/efr.�:�2✓
3 Contractor,Agent
Phone
2G VLZ SCS
m3 SGL (
State License 7- 14 Approv /
�h umbmg lnspector r/
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatorics To Existing
Kitchen
Dish Washer
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Size
Water Softener Material
Bar Sink To Main Drain
Comb.Sink&Tray To Curb
Dental Unit
Drinking Fountain
Floor Drain WATER SYSTEM
Hopper UMatena
Restaurant Sink
Relief Valve I Ga�s Fee
Sand TrapEES
Urinal ,d 0
Area Drain e
Wa L eSprinkler System
Vac Breaker
Skimmer
.Filter
Permit Fee -2 , 00
Total Total Fee D D